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Minni <br />Well and Boring <br />OR BORING LOCATION Sealing <br />57009 7 O O <br />MINNESOTA DEPARTMENT OF HEALTH ea6 NN o f7 u 1J,7 <br />County Name _-----------� - WELL AND BORING SEALING RECORD MlnnesolaUniqueNo - <br />HttL.�... Minnesota Starules Chapter 1031 or Wsenes No <br />e Y• •i r•,�.r I'.InY ,1rpt YrHMri�-_ - ____ d <br />Township Name Township No Range No Section No t r•rctlon Ism • lg 1 Date Sealed Approximate Date Wen <br />Or_cx+n 118 23 36 4 WO 1,5 or Boring Constructed <br />_ <br />N. �i-if Sheol <br />Address or Fire Number aannd.�Cay of Well or Boring Location p , l �04 <br />119 \ A. VY � D • Orc W 55391 Depth Belore Seahny---���_ __ _ it ong"I Depth - II <br />Snow eaact location of well or boring Sketch map of well or bonny Static Water Level curate <br />—lion grid with K location showing property lines <br />j it ds and qtr rigs El Approximate <br />IN S • .. J Il . }]t <br />ogle A,Iwfer ❑ Muthaquder _ it _— A below above land surlace <br />i r r i fI — <br />W -- E V <br />I i reel ❑ Plastu: ❑ Tile ❑ Other <br />S Screen Irom — ----- to ---- 11 Open Hole hom — Io__ It <br />Imo— .* —moi OOBSTRUCTIOPWiSPISiFILL <br />/ <br />PROPERTY OWNER'S NAME oostruction ❑ Debris ❑ f dl <br />Jetj w0ek 47b-[931, <br />- ----- - -- — - — Type of debnvolosin chon _ L1Lf le <br />Meil,nq A&Y1•• d ddlemnt than property address rndica•ed above <br />ObsfructioNDebns'Fill rcHnovcd"' Ale, ❑ No <br />PUMP <br />Removed ClNot Present ElOther 54AP PCrmP <br />CASING <br />GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br />FORMATION <br />It riot known, indicale estimated formation log from nearby well or boring Diameter Depth Set in oversize holel' Annular space indralty, grouted' <br />drift_ in from Io.. It ❑ Yr a VN. ❑ Yes ❑ No ❑ Unknown <br />_ io birth to 11 ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />in from _._ to 1t ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />-- - ------— METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS. OR CASING AND BORE HOLE: <br />No Annular Space Exists <br />❑ Annular space growled with berme pipe <br />— --- -- — ❑ Casing PadoratiorvRemoval <br />-- in from to -- it ❑ Podorated ❑ Removed <br />in from to it ❑ Pedoraled ❑ Removed <br />-- Type of pedorator <br />—___..._.. ❑ Other <br />GROUTING MATERIAL <br />Grouting malenal 04'e 0o 7 !/hf N/ born— to til it yards , bags <br />from __— to ti yards bags <br />REMARKS. SOURCE OF DATA. OIFFICULTtES IN SEALING <br />from _ to —_— ti —_ yards nags <br />from — to _ _ it yards Sags <br />22 UNSEALED WELLS AND BORW6S <br />AUGj Uf �' (Mhei unsealed well of boring on propertyl ❑ Yea 361. <br />LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br />This well or boring was sealed in accordance with Minnesota Hubs. Chapbv, C . M.,mation contained in Mrs report,s <br />true to the best of my knowledge <br />Dan 5t .1ola well Drilling 1w. 27172 <br />Conlra[Yor %sirress Name License iv Neorstrahon No -- <br />• <br />r t ne'f"r,' mrzd" Sgnaaue Daly <br />x 7 0 0 9 Jim An`ons' <br />x �L t tv H -- -- <br />,,, ,INoaaHrxrny <br />